Pre-licensing visit·July 28, 2021

Licensing Program Analyst (LPA) Praveen Singh arrived to conduct an announced Pre-Licensing inspection. LPA met with Applicants/Administrators David Kim and Jina Kim. Prior to initiating the Pre-Licensing inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; contacted Facility Representative and completed a facility risk assessment. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. LPA and administrators toured the home together, common areas, dining room, kitchen, backyard and resident rooms. Facility has five (5) resident bedrooms, and three (3) bathrooms. Bathrooms were equipped with grab bars and non-skid mats and hot water temperature in bathroom measured at 107.7 degrees F. Resident bedrooms were equipped with required furniture and smoke detectors and carbon monoxide detectors were present. Fire extinguisher was observed to be fully charged. Facility's fire clearance was granted on 6/17/21. Administrator understands that a 2 day perishable and 7 day non-perishable food supply needs to be on hand prior to accepting residents. LPA observed there are adequate amounts of linens, towels, and dishes at the facility. LPA observed locked drawers and cabinets for sharps, toxins, and cleaning supplies. LPA observed a locked medication cart for centrally stored medications. The facility will utilize a medication administration record (MAR). First aid kit was found to be complete. LPA reviewed sample staff and resident files and found required forms to be in the files. Administrator stated that disaster drills will be completed and documented at minimum every three months. Facility has a second floor that is blocked off and inaccessible to residents. LPA observed that facility is ready to be licensed. This report will be submitted to the Centralized Applications Bureau (CAB) and a final review of the application will be conducted. This facility is not yet licensed, and is subject to final approval by CAB. Additional requirements may still be required. Exit interview conducted and copy of report provided. [See LIC809 (Case Management Report) dated 7/28/21, for Comp III Review Conducted today]